Health promotion approach to reduce unintentional home injuries of young children in rural villages in the North Central Province of Sri Lanka

Background: South East Asian region reports a higher risk for deaths from injuries and in Sri Lanka 16% child mortality is due to injuries. Objectives: To describe the types and extent of unintentional home injuries among children below 5 years of age, to evaluate the knowledge, attitudes and current practices of primary caregivers on reducing unintentional home injuries in two villages and to assess the effectiveness of a health promotion approach in rural villages in the North Central Province of Sri Lanka. Method: A quasi experimental study was carried by selecting 2 rural villages. Baseline measures were gathered in experimental and control areas using a questionnaire, a history record index and a practice checklist. A health promotion intervention was administered in the experimental study area. The intervention was developed consulting the community and targeted identifying determinants of unintentional home injuries and improving knowledge, changing attitudes, obtaining family support and improving skills on identifying risks for home injuries. The health promotion intervention was delivered through lectures and activities. Post evaluation assessment was on change in practices which was the primary outcome, and the change in knowledge and attitudes were secondary outcomes. Results: Injury prevalence was 31% (CI 20.543.1), burns (36.4%) being the most common. The difference between pre and post scores of mean practice was significantly higher (p=0.001) in the intervention group which showed knowledge improvement and a positive change in attitudes. Conclusions: Nearly one third of caregivers reported a home injury and the health promotion _________________________________________ Rajarata University of Sri Lanka. Faculty of Medicine, University of Colombo, Sri Lanka *Correspondence: nayanahwg@gmail.com (Received on 25 March 2017: Accepted after revision on 16 June 2017) The authors declare that there are no conflicts of interest Personal funding was used for the project. Open Access Article published under the Creative Commons Attribution CC-BY License intervention was effective in improving injury prevention practices, knowledge and attitudes. DOI: http://dx.doi.org/10.4038/sljch.v47i1.8427 (


Background
In developing countries injuries are a major cause of death among 1-5 year old children 1 .A South East Asian community survey showed that 30% deaths of 1-3 year old children and 40% deaths of 4 year old children were related to injuries 2 .Most injuries among children below 5 years are reported to occur at home as they often live around and outside home 3 .The common causes of injuries are accidental burns caused by kerosene lamps, scalding by water and intentional acts among children between 1-4 years of age 4 .Prevention of childhood injuries and accidents remains a key issue and a priority health area in Sri Lanka 5 .
Many studies reveal that parents and caregivers can prevent childhood injuries by addressing their own behaviour and risky environmental factors around them 6,7 .The main factors identified as contributing to unintentional injuries are children's physical characteristics, socioeconomic factors in the family and parental and caregiver factors 8,9 .The parental factors are the attitudes and beliefs on possible accidents to their children, previous incidents, severity of injuries and ability to identify or predict a risk.Awareness and knowledge on consequences of child injuries and means of injury prevention also determine the degree of adopting the above practices 7 .
Parents and caregivers in many developed countries are educated and are conscious in making childproof houses, taking preventive measures for a safe home and play environment for children 10 and installing readymade safety devices for child proofing homes 11 .Sri Lankan communities do not focus much on making child proof houses and usage of safety devices.However, if the community is empowered, it is possible to develop and practise such behaviours by the community in a sustainable way.Health promotional models have been used to empower parents and caregivers to prevent home injuries among children.

Objectives
To describe the types and extent of unintentional home injuries among children below 5 years of age and to evaluate the knowledge, attitudes and current practices of primary caregivers on reducing unintentional home injuries in two villages and to assess the effectiveness of a health promotion approach in rural villages in the North Central Province of Sri Lanka.

Design and sample
The baseline study was conducted in Wannammaduwa and Nambadagaswewa villages in the North Central province.One village was selected as the interventional group and the other village as the control group for the assessment of the health promotional approach.Selections were done randomly.The post-evaluation was carried out 3 months after completion of the intervention in both areas.All eligible families i.e. families having a child between 0-5 years of age, under the care of the public health midwife (PHM) in the village, were selected.This included 36 families from the experimental area and 35 from the control area.The participant was the primary caregiver defined as "a parent or caregiver both male and female, of children below 5 years of age spending most of the time caring for the children".Parents and caregivers of disabled children, who stay away from home and do not often visit their children and parents with psychiatric illness were excluded from the study due to their sensitive and specific lifestyle pattern.Figure 1 is a flow diagram of the study.

Measures
An interviewer administered questionnaire was used to assess the sociodemographic characteristics, knowledge of parents and caregivers on definition of accident, types of accidents, forms and extent of harm caused, risk factors, necessity for prevention, attitudes towards home safety and feasibility of preventing unintentional home injuries.A history record index assessed the previous history (types and extent) of injuries, age at injury, type and mode of injury, harm caused and safety measures taken to prevent further injuries.To assess the household practices, a checklist with 30 safety practices was used.Practices were monitored in five places in the house: kitchen, bath place, bedroom, living room and compound.Each practice was separately observed and measured according to a Likert-type of scale e.g.very attentive, attentive to some extent, very little attentive / not attentive at all.If any safety measure was taken to remove a risk or an accident at the above places, that was considered as a highest scored practice.If there were no measures taken to remove the risk but they have thought of and seen the risk, those practices were given the middle mark and if they hadn't seen or thought about the risk, those practices were given the lowest mark.Thereafter, a practice score was calculated from a list of practices observed through home visits.The primary outcome measure was the change of the mean practice score between baseline and 3 months after the intervention.Secondary outcomes were percentage changes of knowledge and attitudes between baseline and follow-up.

Data collection procedure
The principal investigator (PI) carried out the data collection in village monthly weighing clinic or the participants' homes in both experimental and control study areas.All houses had a home visit where the PI spent at least 15 minutes for the observation of practices during which time the checklist was completed.Informed written consent was obtained from all participants.Permission to carry out the study and the intervention was obtained from the local and regional health officials and from the Department of Biological Sciences of the Rajarata University of Sri Lanka.

Health promotion intervention
Development of the intervention was based on a health belief model which explains that preventive behaviours are a function of people's beliefs about their susceptibility to the health problem, the severity of the health problem, the benefits versus costs of adopting the preventive behaviour 12 , and the fact that health promotion is capable of driving the participants to take control over the determinants that govern their lives.

Development of the intervention:
The health promotional intervention was developed with the participation of the caregivers in the intervention group.Four groups were formed where 18 volunteer participants gathered once in two weeks with the PI.Determinants for poor safety practices of parents and caregivers to reduce injury occurrence were discussed and identified.Initially participants' understanding on determinants was enhanced.PI facilitated to bring out unrecognized factors by the participants and they agreed on them after analysing them within the group.The outcomes were written in papers by one of the participants in a group throughout the discussions.All four groups developed lists of determinants for each group identified.Thereafter, the PI prepared a summarised document and used it to plan intervention with participants, which included factors such as lack of ability to guess or identify risks in home and behaviour, poor family support for creating a safe environment, lack of enthusiasm and poor cohesion of family, not having common feeling/ cohesion among villagers, attitudes and beliefs like "my child will not face any risks or accidents", "child will not experiment risky acts" and "as a caregiver I will always be cautious and will not make any mistakes" and poor awareness/ knowledge on childhood injuries.

Delivery of the health promotion intervention:
Interactive discussions were conducted using visual aids.The questionnaire used at the survey was taken as a guide to discuss about the unknown facts on childhood unintentional injuries.Participants' attitudes were also addressed during these discussions.Participants' ability to identify risk factors at home were strengthened by picture puzzles during group discussions where pictures of model houses with risk factors were shown and participants were given the opportunity to identify risks.Home visits were made to each house in the intervention group to observe and the removal of risk factors from home also contributed to identifying risk factors.Changes which needed time were emphasised and advice was given to remove the dangers in due course.During the follow up sessions, interactive discussions were held with the use of visual aids to identify the possible risk factors at home and participants were asked to explain possible injuries that can occur and suggest precautions to remove the risks.

Statistical analysis
Statistical Package for Social Sciences (SPSS) version 16.0 was used for data entry and analysis.Random checks were performed on 10% of the data to ensure accuracy.Each practice was given a score ranging from 0-3 and a total score was calculated for each participant.Effectiveness of the intervention was assessed by comparing practices of the pre and post data in both study areas separately using the paired t-test.Differences of the knowledge and attitudes were compared in the two study communities by comparing their proportions.

Results
Table 1 shows the sociodemographic characteristics of the intervention and control groups.Education less than Ordinary Level (O/L) in mothers and fathers in intervention group was 69.4% and 81% while in control group it was 54.3% and 57.1% respectively.Levels of education up to Advanced Level (A/L) were higher among mothers and fathers in the control group than in intervention group.Majority of mothers in both groups were unemployed.Majority of "other caregivers" were grandmothers in both groups.The types and extent of unintentional home injuries are shown in Table 2.
Home injuries: Prevalence of unintentional home injury was 31% (CI 20.5-43.1) in both study areas.Out of all types of injury, burns was the highest (36.4%) followed by cuts and falls (18.2%).Chemical ingestions were few (13.6%).Majority has required hospital admission and the injury had occurred in the kitchen or garden.Nearly 80% of injuries had occurred when someone had been near or around the child.
Practices: The practice score difference after the intervention was significantly different in the intervention and the control group (p<0.001), with a higher mean difference in the intervention group.Table 3 compares the mean score and changes in score of practices Knowledge and attitudes: Table 4 shows the different aspects of knowledge increments and attitude changes at pre and post intervention in both study groups.Comparison of percentage differences in intervention and control groups shows that intervention has a higher percentage change than the control group.Attitudes towards the possibility of child meeting with severe accidents at home to which the answer "yes may be" changed in intervention group from 86.1% to 94.4% while in control group it was from 83.4% to 88.7%.

Discussion
Though there is prevalence data of road traffic accidents and related injuries 13 , home based injuries are not properly documented in health care centres 14 .
This study was a baseline study and development of intervention and the assessment of the health promotion intervention.This may be an important source of information for future research and policy making.The injury prevalence in these areas was 31%.This value is close to 28.  15 reported that in Singapore, 51% of injuries occurred in the kitchen.
Burns were a common type of injury in the present study.A study in a selected community in Sri Lanka showed falls (74%) as the commonest cause among 0-5 year children followed by falling objects, animal attacks and burns 14 .At global level drowning and fire related burns are common injuries among 1-4 year children followed by falls and poisoning 13 .Most home injuries (82%) had occurred when someone was near or around the injured child.This evidently shows that the main determinant factors for injuries are: inability to predict accidents, poor supervision, and carelessness of parents or caregivers.However, results from the study of Morrongiello BA et al. (2004) revealed that approximately 67% of injuries occur when mothers were not in the same room with their child 7 .Suffocation (21%) and drowning (19%) were the least identified types of injury by participants in this study.It is known that suffocation is a common injury among infants 16 .These aspects of knowledge are important for parents as awareness of the potential dangers makes one more cautious and promotes caregivers to create a safe surrounding for children.
Studies highlight the fact that mere delivery of an intervention is not effective if there is no perceived need to the community 16,19 .Community should gain control over determinants of their life to make changes, this being the main principle of health promotion.Bringing out solutions from the community itself or by their choice, rather than by compulsion, thus creating long lasting success 20 was the hallmark of the intervention in this study.Further, if the community takes control over determinants in their life, there may be more positive changes, which are in the long term, sustainable 21 .
The history record index was a successful tool in assessing unintentional injury in children since it descriptively collected case records of the injury.However, consideration should be given to the fact that there might be a possibility for recall bias and over-or underreporting of the number of injury types and frequency.Practices assessment through home visit observations and discussion with residents ensured quality of data.Another limitation is that the study was carried out in only two small villages limiting the number of eligible participants.Expansion of the study area would have overcome this problem.The strength of this study was determining the underlying factors through interactive group discussion within groups.Mutual understanding and mutual relationships acted as a foundation for success.

Conclusions
Nearly one third of caregivers reported a home injury and the health promotion intervention was effective in improving injury prevention practices, knowledge and attitudes.